Contrast-enhanced ultrasound combined with ultra-high-frequency ultrasound improves preoperative planning for lymphovenous anastomosis: A pilot study.

Lymphatic-venous anastomosis (LVA) is an effective surgical treatment for lymphedema, which requires accurate identification of lymphatic vessels. Indocyanine Green (ICG) lymphography, the most common method for lymphatic mapping, cannot always successfully identify lymphatic vessels. We aimed to explore high-frequency ultrasound (HFUS) and contrast-enhanced ultrasound (CEUS) as a reliable alternative for lymphatic mapping when ICG lymphography is not feasible. We performed combined HFUS and CEUS for lymphatic mapping on the patients who exhibited no obvious linear pattern on ICG lymphography. The inner and outer diameters and depths of the lymphatic vessels were measured. We subsequently evaluated the accuracy of US lymphatic mapping by comparing it with the operative results. And the postoperative volume and circumference of the affected limbs were compared with the preoperative measurements. We recruited 111 patients with lymphedema, including 96 limbs and 24 perineal areas affected. Three hundred forty-five lymphatics in the limbs and 52 in the perineum underwent anastomosis and were analyzed. Comparable lymphatic vessel diameter (inner: 0.5-0.9 mm; outer: 0.8-0.9 mm) and depth (9-10 mm) measurements across HFUS, CEUS, and combined HFUS + CEUS. However, HFUS + CEUS significantly improved detection sensitivity, identifying 313 vessels (91.1% accuracy) vs 114 (88.6%) for HFUS and 22 (90.9%) for CEUS. Significant postoperative reductions in limb circumference (39.3 ± 7.4 cm to 37.8 ± 7.1 cm) and volume (81.1 ± 35.8 L to 74.2 ± 33.4 L, p < 0.001). All ultrasound methods consistently showed volume reduction (HFUS: 93.3 ± 25.4 L to 89.6 ± 24.1 L; CEUS: 92.4 ± 28.9 L to 83.4 ± 19.8 L; HFUS + CEUS: 91.2 ± 31.8 L to 84.2 ± 21.5 L, p < 0.001-0.002). High-frequency US combined with CEUS serves as a reliable pre-op lymphatic mapping alternative when ICG lymphography fails. Question In over 40% of lymphedema patients, preoperative ICG lymphangiography fails to show a linear pattern; can HFUS and CEUS provide complementary information? Findings ICG failed to visualize in 42.53% of patients; HFUS and CEUS identified lymphatics in all and achieved 94.5% accuracy. Clinical relevance This study confirmed that HFUS combined with CEUS improves the detection of lymphatic vessels and the success of LVA in ICG-negative cases.

Contrast-enhanced Ultrasound for Assessing Pre-operative Lymphatic Vessel Function and Post-operative Anastomotic Patency in Lymphatic-venous Anastomosis: A Retrospective Observational Study.

BackgroundWe evaluated the application of preoperative ultrasound (US) combined with indocyanine green (ICG) lymphography in lymphaticovenular anastomosis (LVA) of the lower limb.Methods66 patients with lower limb lymphedema were selected as study subjects and divided into research (n = 35) and control groups (n = 31). The patients were treated with LVA using ICG lymphography combined with US and simple ICG lymphography as the positioning method. The number of lymphatic vessels anastomosed, diameter, depth, and searching time were compared.ResultsThe number of anastomotic lymphatic vessels in the research group was more than in the control group (p < .05). Compared with the lymphatic vessels under ICG lymphography, the lymphatic vessels under US locating had less search time, larger diameter, and deeper depth (p < .05).ConclusionUS combined with ICG lymphography in preoperative can increase the number of lymphatic vessels and shorten the time to find lymphatic vessels.

We have described a procedure to minimize surgical wounds, in which lymph vessels and skin venules are identified by indocyanine green (ICG) lymphography and the AV300 noncontact visualization system (AccuVein, Cold Spring Harbor, NY), respectively. This approach allows accurate decisions regarding sites of incision for lymphatic venous anastomosis (LVA). This method was applied in a patient with right upper-limb lymphedema after breast cancer therapy. The low-invasive procedure can be used before and during surgery. The incision size is minimal, and the incision site is at the joint area. Thus, we aim to establish this approach as a standard method for identifying lymph vessels and veins that are suitable for LVA. This innovative vascular-imaging machine makes LVA less invasive and more effective without side effects.

Lymphatic venous anastomosis (LVA) is a widely accepted surgical procedure for lymphedema. To obtain the best outcomes, surgeons should be well trained. A recent study introduced an LVA training model using pig trotters for their utility and structural similarity to human tissues. However, details regarding the utilization of anastomosis models, such as feasible points for training based on vessel anatomy, have not been clarified. Therefore, we assessed the anatomical details of lymphatic vessels and veins of trotters to establish a practical training model of LVA. Ten frozen trotters were used. After thawing at room temperature, indocyanine green fluorescent lymphography was used to visualize the lymphatic course. To dissect the lymphatic vessels and veins from the distal to the proximal end, whole skins were detached thoroughly from the plantar side. Data from the lymphatic vessels and veins were collected based on their courses, diameters, and layouts to clarify adjacent points feasible for LVA training. Both lymphatic vessels and veins were classified into four major courses: dorsal, medial, lateral, and plantar. The majority were dorsal vessels, both lymphatic vessels and veins. The adjacent points were always found in the distal dorsum center and were especially concentrated between the metacarpophalangeal (MP) joint and central interphalangeal crease, followed by the medial and lateral sides. The most relevant point for LVA surgical training in the trotter was the dorsal center distal to the MP joint, where parallel vessels of similar sizes were found in all cases. This practical LVA surgical model would improve surgeon skills in not only anastomosis but also preoperative fluorescent lymphography.

INTRODUCTION: There are several lymphatic diseases that could be treated surgically. Lymphatic venous anastomosis (LVA) was developed to improve lymphedema. On the other hand, in children settings, the majority of lymph diseases are not lymphedema, but lymphangioma or also called lymphatic malformations (LM). This LM especially micro-cystic type LM (mLM) had been challenging to treat because the conventional therapy had been limited efficacy and highly cause complications. To change the strategy, focusing on the lymph flow was the key for this disease. Thus we modified and analysed LVA to improve mLM of children. METHODS: We indicated 14 sequential cases of mLM patients who appeared to our clinic from July 2015 to June 2016, 10 males and 4 females, between 0 to 12 (mean 4) year-old. All cases underwent indocyanine green (ICG) lymphangiography and modified LVA under general anesthesia. Single surgeon (presenting author) performed all surgeries. Depend on the ICG findings of flow pattern we classified anastomosis manners into 2 groups; 1, LVA to decrease the in-flow and 2, increase the out-flow directly from the cysts. RESULTS: In all cases successful assessment with ICG were possible. 11 out of 14 (79%) cases were improved their situations such as size decrease, vesicle disappearance, or prevent following functional loss. Only one case increased vesicles on the surgical site. No complications such as allergy reactions, lymphorrhea, functional loss, surgical site infections or post-operative bleeding were observed. CONCLUSION: We applied ICG and modified LVA for mLM patients and found they are effective. This flow oriented surgical strategy with ICG and LVA for LM was very unique. To our best knowledge, this is the first report that shows the effectiveness of ICG and of LVA on LM. mLM were considered that related to the obstruction of lymph flow proximally. Conventional surgeries were limited, so this surgical strategy could be a break-through for this challenging disease. And also ICG and LVA could spread their indications to a new field. The limitation of this study was the short time follow-up period after the surgery, so more cases should be indicated.

Lymphoscintigraphy and indocyanine green (ICG) lymphography reveal the severity of extremity lymphedema. Lower extremity lymphedema (LEL) index and NECST classification are related to the clinical severity of lymphedema. We aimed to investigate the correlation between lymphatic surgery, lymphatic imaging, and clinical severity in patients with lymphedema. Thirty-five patients with lower-extremity lymphedema who underwent lymphatic venous anastomosis (LVA) were evaluated. Ten of the thirty-five patients underwent multi-surgery (additional vascularized lymphatic transfer and/or liposuction). We investigated the correlation between the LEL index, NECST classification, lymphoscintigraphy staging, ICG lymphography staging, and rate of improvement (RI: [preoperative LEL index − postoperative LEL index]/[preoperative LEL index] × 100). The LEL index in 35 patients after LVA and all procedures decreased significantly compared to that of preoperative (272.4 vs. 256.2 vs. 243.5, p < 0.05). RI after LVA and all procedures showed positive correlations with the preoperative LEL index; however, there was no correlation with any other lymphatic image or clinical severity. LVA can reduce lymphedema circumference at any stage. Additional surgery improved the circumference. Hence, LVA as the first line of treatment, and vascularized lymphatic transfer and liposuction as additional procedures, should be considered as the standard treatment for lymphedema.

Peri-orbital lymphangioma treated by lymphatic-venous anastomosis with indocyanine green lymphography analysis

Background:Lymphaticovenous anastomosis (LVA) is an effective surgical treatment for extremity lymphedema. Indocyanine green (ICG) fluorescent lymphography, the traditional standard for imaging lymphatic vessels, has limitations, including difficulty depicting deeper or congested lymphatics and contraindication in iodine hypersensitivity. This study evaluated contrast-enhanced ultrasound (CEUS) with microbubbles for identifying lymphatic vessels for LVA and compared it with ICG lymphography.Methods:In this single-center retrospective review, intraoperative CEUS with intradermal injection of microbubble suspension (Lumason, Bracco Diagnostics, Inc.) was used in patients before LVA surgery between October 2019 and February 2023. Pre- or intraoperative ICG lymphography was also used to identify target lymphatic vessels. All patients diagnosed with primary or secondary extremity lymphedema who underwent LVA were included. Technical success rate was defined as lymphatic vessels identified by CEUS that led to successful LVAs. Descriptive statistics were used.Results:Thirty-two patients underwent LVA surgery, with a mean age of 58.5 ± 13.9 years. CEUS identified lymphatic vessels in all 32 patients, including 7 in whom ICG failed. Two patients with ICG allergy underwent CEUS only. CEUS identified more candidate lymphatics per patient (5.3 ± 4.2) compared with ICG (2.5 ± 2.7). Of the 182 anastomoses, 96 (52.8%) were identified by both CEUS and ICG, 75 (41.2%) by CEUS only, and 11 (6%) by ICG only.Conclusions:CEUS is a promising tool for identifying lymphatic vessels in patients with lymphedema undergoing LVA, particularly when ICG lymphography is inadequate or contraindicated.

Identification of functional lymphatic vessels and localization of lymphatic vessels are important for lymphaticovenular anastomosis (LVA). Indocyanine green (ICG) lymphography is useful for localization of superficial lymphatic vessels where dermal backflow is not observed, but not for lymphatic vessels in deep layer or where dermal backflow is observed. Ultrasound has been applied in LVA and is considered useful for localization of lymphatic vessels with ICG lymphography cannot be visualized. Fifty-five secondary lower extremity lymphedema (LEL) patients who underwent LVA were classified into two groups, ultrasound-detection-of-lymphatic group (US group, n = 29) and non-ultrasound-detection-of-lymphatic group (non-US group, n = 26), and assessed. Sensitivity and specificity to detect lymphatic vessel were evaluated in US group. Intraoperative findings, required time for dissecting lymphatic vessels and veins, length of skin incision, and postoperative lymphedematous volume reduction were compared between the groups. Lymphatic vessels were detected in all incisions in both groups. LVA resulted in 232 anastomoses in US group and 210 anastomoses in non-US group. Sensitivity and specificity of ultrasound for detection of lymphatic vessels were 88.2% and 92.7%, respectively. Diameter of lymphatic vessels found in US group was significantly larger than that in non-US group (0.66 ± 0.18 vs 0.45 ± 0.20 mm; P = 0.042). Time required for dissecting lymphatic vessels and veins in US group was shorter than that in non-US group (9.2 ± 1.7 vs 14.7 ± 2.4 min; P = 0.026). LEL index reduction was significantly greater in US group than that in non-US group (26.7 ± 13.6 vs 7.8 ± 11.3; P = 0.031). Ultrasound-guided detection of lymphatic vessels for lymphedema was performed with high precision, and allows easier and more effective LVA surgery.

Supermicrosurgical lymphatic-venous anastomosis (LVA) can improve limbs lymphedema. We describe a technique that we employ for preoperative lymphatic mapping of the upper limb (UL), when indocyanine green (ICG) lymphography shows only dermal backflow (DB) and no lymphatic vessel is detectable. Sixteen patients undergoing LVA for unilateral UL lymphedema, showing "stardust" or "diffuse" DB pattern, were included. Demographic, clinical data, and limbs measurements were recorded. LymQoL arm questionnaire was administered. Mean age of patients was 58.8±13.1years. Fifteen were females and 1 male. Lymphatic anatomy of the healthy limb was investigated by ICG lymphography and reported on the affected limb by a four steps technique: marking the main lymphatic pathway on the healthy limb, measuring of the distances at seven levels between the pathway and a line joining fixed landmarks, reporting these measurements on the affected limb with a correction proportional to the degree of swelling, marking skin incisions at the intersection of this pathway with venules, individuated by near infrared light system. Results were analyzed by postoperative questionnaire and changes of limb measurements. For every limb, we could find 3±0.73incision sites each containing at least one lymphatic vessel suitable for anastomosis. In every patient, we could perform 3.38±0.62 anastomoses. Mean follow-up was 12.13±2.73months. After surgery, mean preoperative QoL score increased from 5.5to 7.9 (P<.001), and mean difference between the mean circumferences of the affected and healthy limbs decreased from 4.3±1.3 to 2.5±1.3cm, showing improvement of swelling after surgery (P<.01). This technique allowed to preoperatively map UL lymphatics even if diffuse DB was present.

Lymphatic ultrasound detects more vessels than indocyanine green lymphography in lymphedematous limbs.

ObjectiveHepatocellular carcinoma (HCC) is the most common cause of primary liver cancer. A major part of diagnostic HCC work-up is based on imaging findings from sonography, computed tomography (CT), or magnetic resonance imaging (MRI) scans. Contrast-enhanced ultrasound (CEUS) allows for the dynamic assessment of the microperfusion pattern of suspicious liver lesions. This study aimed to evaluate the diagnostic value of CEUS compared with CT scans for assessing HCC.MethodsWe performed a retrospective, single-center study between 2004 and 2018 on 234 patients with suspicious liver lesions who underwent CEUS and CT examinations. All patients underwent native B-mode, color Doppler and CEUS after providing informed consent. Every CEUS examination was performed and interpreted by a single experienced radiologist (European Federation of Societies for Ultrasound in Medicine and Biology level 3).ResultsCEUS was performed on all included patients without occurrence of any adverse effects. CEUS showed a sensitivity of 94%, a specificity of 70%, a positive predictive value of 93% and a negative predictive value of 72% for analyzing HCC compared with CT as the diagnostic gold standard.ConclusionsCEUS has an excellent safety profile and shows a high diagnostic accuracy in assessing HCC compared with corresponding results from CT scans.

The Influence of Multipoint Indocyanine Green Injections on the Outcome of LVA Surgery in Patients with Lower Limb Lymphedema.

To assess the clinical efficacy of contrast-enhanced ultrasound (CEUS) combined with indocyanine green (ICG) lymphography for the treatment of breast cancer-related lymphedema (BCRL). Fifty-two patients with BCRL who underwent lymphaticovenous anastomosis between March 2022 and March 2024 were enrolled, of whom 22 underwent preoperative functional lymphatic vessel localization using ICG lymphography alone and 30 received CEUS combined with ICG lymphography. Treatment efficacy was evaluated using bioimpedance spectroscopy for segmental water content analysis, calculation of the upper extremity lymphedema (UEL) index, and administration of the Lymphedema Quality of Life Questionnaire (LYMQOL). Surgical parameters were also analyzed. Baseline characteristics were comparable between the groups. However, at both 6 and 12 months postoperatively, patients in the CEUS+ICG group demonstrated significantly improved outcomes compared to those in the ICG-only group, including: Reduced segmental water differences (6 months: 344.3 vs. 474.6 mL, p=0.0221; 12 months: 284.3 vs. 403.6 mL, p=0.0156); Lower UEL index (6 months: 124.2 vs. 134.1, p=0.0010; 12 months: 123.8 vs. 131.9, p=0.0105); Improved LYMQOL scores (6 months: 48.7 vs. 56.6, p=0.0029; 12 months: 47.6 vs. 54.2, p=0.0065). Additionally, the CEUS+ICG group achieved a significantly higher anastomosis success rate (83.2% vs. 63.3%, p<0.001) and reduced procedural time per anastomosis (48.9 vs. 61.6 minutes, p=0.0021). The combination of CEUS and ICG-L is associated with precise preoperative lymphatic mapping, a reduction in unnecessary incisions, as well as better anastomosis success rates and postoperative decongestion outcomes.